Provider Demographics
NPI:1154349389
Name:PORTER, STEPHANIE ANN (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 BUDFIELD ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3213
Mailing Address - Country:US
Mailing Address - Phone:814-262-9500
Mailing Address - Fax:814-262-9142
Practice Address - Street 1:323 BUDFIELD ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3213
Practice Address - Country:US
Practice Address - Phone:814-262-9500
Practice Address - Fax:814-262-9142
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD458454208000000X
TXL3841208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK0122980OtherCONTROLLED SUBSTANCE REGI